1. VERTIGO
AYESHA SHAIKH
PGY2
EMORY FAMILY MEDICINE
09.17.2008
2. CASE
31,female doctor, otherwise healthy,
post partum week 5.
First episode, sudden feeling of room
spinning, while entering patient data in
computer, during Family Medicine
Clinic… One fine day last year same
time!
8. History
Timings
Duration
Provoking, aggreviating factors
Associated symptoms
Risk factors for Cardiovascular disease
Q: When you have dizzy spells , do you feel
lightheaded or do you see the world spin around
you?
Q: Duration of Vertigo and associated symptoms?
( differentiate peripheral vs central causes)
9. Typical Duration of Symptoms for Different Causes of Vertigo
Duration of episode Suggested diagnosis
A few seconds Peripheral cause: unilateral loss of vestibular function; late stages of
acute vestibular neuronitis; late stages of Ménière's disease
Several seconds
to a few minutes Benign paroxysmal positional vertigo; perilymphatic fistula
Several minutes
to one hour Posterior transient ischemic attack; perilymphatic fistula
Hours Ménière's disease; perilymphatic fistula from trauma or surgery;
migraine; acoustic neuroma
Days Early acute vestibular neuronitis*; stroke; migraine; multiple sclerosis
Weeks Psychogenic (constant vertigo lasting weeks without improvement)
*-Vertigo with early acute vestibular neuritis can last as briefly as two days or as long as one week
or more.
Information from references 3, 6, and 12.
10. Provoking Factors for Different Causes of Vertigo
Provoking factor Suggested diagnosis
•Changes in head position Acute labyrinthitis; benign positional paroxysmal vertigo; cerebellopontine angle tumor;
multiple sclerosis; perilymphatic fistula
•Spontaneous episodes Acute vestibular neuronitis; cerebrovascular disease (stroke or transient ischemic attack);
(i.e., no consistent Ménière's disease; migraine; multiple sclerosis
•provoking factors)
•Recent upper respiratory
viral illness Acute vestibular neuronitis
•Stress Psychiatric or psychological causes; migraine
•Immunosuppression
(e.g., immunosuppressive Herpes zoster oticus
medications, advanced age
, stress)
•Changes in ear pressure, Perilymphatic fistula
head trauma,
excessive straining, loud noises
•Information from references 1, 3, 5, 12, and 13.
11. Associated Symptoms for Different Causes of Vertigo
Symptom Suggested diagnosis
Aural fullness Acoustic neuroma; Ménière's disease
Ear or mastoid pain Acoustic neuroma; acute middle ear disease (e.g., otitis media, herpes zoster oticus)
Facial weakness Acoustic neuroma; herpes zoster oticus
Focal neurologic Cerebellopontine angle tumor; cerebrovascular disease;
findings) multiple sclerosis (especially findings not explained by single neurologic lesion
Headache Acoustic neuroma; migraine
Hearing loss Ménière's disease; perilymphatic fistula; acoustic neuroma; cholesteatoma;
otosclerosis; transient ischemic attack or stroke involving anterior inferior cerebellar
artery,herpes zoster oticus
Imbalance Acute vestibular neuronitis (usually moderate); cerebellopontine angle tumor
(usually severe)
Nystagmus Peripheral or central vertigo
Phonophobia, photophobia Migraine
Tinnitus Acute labyrinthitis; acoustic neuroma; Ménière's disease
Information from references 1, 6, and 12 through 14.
12. Table 5
Causes of Vertigo Associated with Hearing Loss
Diagnosis Characteristics of hearing loss
Acoustic neuroma Progressive, unilateral, sensorineural
Cholesteatoma Progressive, unilateral, conductive
Herpes zoster oticus
(i.e., Ramsay Hun
syndrome) Subacute to acute onset, unilateral
Ménière's diseases Sensorineural, initially fluctuating, initially affecting lower
frequencies;
later in course: progressive, affecting higher frequencies
Otosclerosis Progressive, conductive
Perilymphatic fistula Progressive, unilateral
Transient ischemic attack or
stroke involving anterior inferior cerebellar
artery or internal auditory artery Sudden onset, unilateral
Information from references 9, 12, and 13.
13. Distinguishing Characteristics of Peripheral vs. Central Causes of Vertigo
Feature Peripheral vertigo Central vertigo
Nystagmus Combined horizontal and torsional; Purely vertical, horizontal, or torsional
inhibited by fixation of eyes onto object; ; not inhibited by fixation of eyes onto object;
fades after a few days; does not change may last weeks to months
direction with gaze to either side ; may change direction with gaze
Imbalance Mild to moderate; able to walk Severe; unable to stand still or walk
Nausea May be severe Varies
, vomiting
Hearing loss,
tinnitus Common Rare
Nonauditory Rare Common
neurologic
symptoms
Latency following
provocative
diagnostic Longer (up to 20 seconds) Shorter (up to 5 seconds)
maneuver)
Information from references 14 and 15.
15. Physical Exam
Vertical nystagmus is 80% sensitive for
central lesions.
Horizontal nystagmus for peripheral
lesions.
Rhomberg sign : sensitivity 19 % only
for peripheral causes.
Dix-Hallpike maneuver PPV 83%, NPV
52 %.
16.
17. Clues to Distinguish Between Peripheral and Central Vertigo
Clues Peripheral vertigo Central vertigo
Findings on Latency of symptoms None
Dix-Hallpike and nystagmus 2 to 40 seconds
maneuver
Severity of vertigo Severe Mild
Duration of nystagmus Usually< 1 minute Usually>1 minute
Fatigability* Yes No
Habituation† Yes No
Other findings
Postural instability Able to walk; Falls while walking;
unidirectional instability severe instability
Hearing loss
or tinnitus Can be present Usually absent
Other neurologic
Symptoms Absent Usually present
*-Response remits spontaneously as position is maintained.
†-Attenuation of response as position repeatedly is assumed.
Information from references 3 and 4.
18. Diagnosis
History
Physical Exam: Orthostatic vital signs, and Otoscopic
examination,
Neurologic Exam: Dix-Hallpike Maneuver ( central vs
Peripheral)
Complete Audiometric Testing for suspected
Menier’s disease
No LAB testing!
Brain imaging : MRI with contrast for acute vertigo and
Sensorineural hearing loss, MRA for vertebrobasilar circulation
19. Disorder Duration Auditory Prevalence Peripheral or
symptoms central vertigo
Benign paroxysmal Seconds No Common Peripheral
positional vertigo
Perilymphatic fistula (head Seconds Yes Uncommon Peripheral
trauma, barotrauma)
Vascular Ischemia,TIA Seconds to hours Usualy not Uncommon Central or
peripheral
Meniere’s disease Hours yes common peripheral
Syphillis Hours yes Uncommon central
Vertiginous migraine Hours No Common Central
Labyrinthitis Days Yes common peripheral
Vascular Ischemia: Stroke Days Usually not Uncommon Central or
peripheral
Vestibular neuronitis Days No Common Peripheral
Anxiety disorder Variable Usually not Common Unspecified
Acoustic neuroma months yes Uncommon Peripheral
Multiple sclerosis Months no uncommon central
Vestibular ototoxicity months yes uncommon peripheral
20. General Treatment Principles
Medication for Acute Vertigo that lasts for few hours
to several days
Medications have various combinations of
acetylecholine, dopamineand histamine receptor
antagonism.
Benzodiazepines enhance GABA action ( GABA is
inhibitory neurotransmitter in vestibular system)
21. Strength of Recommendation
Key clinical recommendation
•The canalith repositioning procedure (Epley maneuver) is recommended in patients with benign paroxysmal
positional vertigo. A
•The modified Epley maneuver also is effective in patients with benign paroxysmal positional vertigo.B
•Vestibular suppressant medication is recommended for symptom relief in patients with acute vestibular
neuronitis. C
•Vestibular exercises are recommended for more rapid and complete vestibular compensation in patients with
acute vestibular neuronitis. B
•Treatment with a low-salt diet and diuretics is recommended for patients with Ménière's disease and vertigo.B
•Effective treatments for vertiginous migraine include migraine prophylaxis (e.g., tricyclic antidepressants, beta
blockers, calcium channel blockers), migraine-abortive medications (e.g., sumatriptan [Imitrex]), and vestibular
rehabilitation exercises B
•Selective serotonin reuptake inhibitors can relieve vertigo in patients with anxiety disorders. Because of side
effects, slow titration is recommended.B
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented
evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. See page 1046 for
more information.
22. Medications
Meclizine* (Antivert) 12.5 to 50 mg orally every 4 to 8 hour
Dimenhydrinate* (Dramamine) 25 to 100 mg orally, IM, or IV every 4
to 8 hours
Diazepam (Valium) 2 to 10 mg orally or IV every 4 to 8 hours
Lorazepam (Ativan) 0.5 to 2 mg orally, IM, or IV every 4 to 8 hours
Metoclopramide (Reglan) 5 to 10 mg orally every 6 hours
5 to 10 mg by slow IV every 6 hours
Prochlorperazine (Compazine) 5 to 10 mg orally or IM every 6 to 8
hours
25 mg rectally every 12 hours
5 to 10 mg by slow IV over 2
minutes
Promethazine (Phenergan) 12.5 to 25 mg orally, IM, or rectally every
4 to 12 hours
23. Vestibular Rehabilitation
Exercises
These exercises train the brain to use alternative
visual and proprioceptive clues to maintain balance
and gait.
Improve postural control during the first month
after acute unilateral vestibular lesions resulting
from vestibular neuronitis.
24. Treatment of Specific Disorders
1- BPPV
(Usually posterior canal Calcium Debris)
MEDS..?
Head Rotation Maneuvers
Eply Maneuver
Contraindication: Severe carotid stenosis, unstable
heart disease, severe neck disease
Success rate: 80 % after one treatment, 100% with
repeated treatments.
Recurrence rates: 15% /year, 20% @ 20 months, and
37% @ 60 months.
25.
26. Treatment of specific Disorders
2- Vestibular Neuronitis
( Acute Prolonged Vertigo)
Symptom relief using vestibular suppressant
medications, followed by vestibular exercises.
Vestibular compensations occurs more rapidly and
more completely if the patient begins twice-daily
vestibular rehabilitation exercises soon after
symptom control with medications.
27. Treatment of specific disorders
3-Menier’s Disease
(Distension of Endolymphatic compartment due to
impaired endolymphatic filtration and excretion)
Low salt diet ( < 1-2 gm/day)
Diuretics ( combo HCTZ and Triamterene)
Surgery in rare cases - ablation of vestibular hair
cells)
28. 4- Vascular Ischemia
(Sudden onset of vertigo with additional symptoms eg
diplopia, ataxia, dysphagia, dysarthria)
TIA /Stroke: BP control, Cholesterol Lowering ,
smoking cessation, inhibition of platelet function,
anticoagulation
Vestibualr suppressant medications plus minimal
head maneuver on first day, then initiate
rehabilitation
Vestibular stents for symptomatic critical vertebral
artery stenosis.
30. 7- Psychiatric Disorders
( Anxiety , Panic disorders more common than depression;
Hyperventilation is the cause.)
Vesibular supressants and Benzodiazepines-
transient to inadequate relief.
SSRI show better relief.
Cognitive behaviour therapy may be helpful.
31. Physiologic Vertigo
Motion sickness: incongruence in the sensory
input from the vestibular, visual, and
somatosensory systems.Visual system does
not sense the movement.
Bring systems back in congruence! Eg watch
horizon when on a boat.also scopolamine
patch behind ear 4 hours before boating.
32. Disorder Duration Auditory Prevalence Peripheral or
symptoms central vertigo
Benign paroxysmal Seconds No Common Peripheral
positional vertigo
Perilymphatic fistula (head Seconds Yes Uncommon Peripheral
trauma, barotrauma)
Vascular Ischemia,TIA Seconds to hours Usualy not Uncommon Central or
peripheral
Meniere’s disease Hours yes Common Peripheral
Syphillis Hours yes Uncommon central
Vertiginous migraine Hours No Common Central
Labyrinthitis Days Yes Common Peripheral
Vascular Ischemia: Stroke Days Usually not Uncommon Central or
peripheral
Vestibular neuronitis Days No Common Peripheral
Anxiety disorder Variable Usually not Common Unspecified
Acoustic neuroma months yes Uncommon Peripheral
Multiple sclerosis Months no uncommon central
Vestibular ototoxicity months yes uncommon peripheral
35. Internet resources for patient
education
http://www.youtube.com/watch?v=hhinu_o
http://www.youtube.com/watch?v=NQr7MK
http://www.youtube.com/watch?v=eOuzUi5
37. References
Labuguen R. Initial Evaluation of Vertigo. American
Family Physician. January 15, 2006.
Swartz R, Longwell P. Treatment of Vertigo.
American Family Physician. March 15, 2005.
Editor's Notes
Leisions that progress slowly or processes that effect both vestibular appratuses equally usualy do not result in vertigo. Also Psychiatric disorders, Motionsickness, Serous OM, Cerumen imapction, HZ, Seizure disorders can also present with diziness.
Vertigo lasting for more than few days is suggestive of permanent vestibular injury ( eg Storke) and medications should be stopped to allow the brain to adopt to new vestibular input. 2- Older patients are at particular risks for side effects ( eg sedations , increased risk of falls, urinary retention., also drug interactions.
It is important for a patient to reexperience vertigo so that the brain can adapt to a new baseline of vestibualr funstion., after acute stablization, use of vestibular suppressant medications should be minimized to facilitate brain’s adaptation. RCT referance.
